Interview with the Author: AfJEM: Michael McCaul on South African pre-hospital guidelines — #badEM

Series: “Interview with the Author…” The badEM crew interviewed Michael McCaul regarding his newly released article in AfJEM Volume 6 Issue 3 entitled: “South African Pre-hospital practice guidelines: Report on progress & way forward” by Michael McCaul, Ben de Waal, Peter Hodkinson & Karen Grimmer Link to open access article: Click here Corresponding author email: mmccaul@sun.ac.za Author’s twitter handle: @MikeMcCaul3…

via Interview with the Author: AfJEM: Michael McCaul on South African pre-hospital guidelines — #badEM


Filed under: Prehospital medicine Tagged: badem, prehospital

What are Potential Health Problems Associated with Polycystic Ovary Syndrome?

Patient Presentation
A new patient, 16-year-old female came to clinic with bilateral knee pain for 2 weeks. She said her knees hurt more as the day went on and with more physical activity. They felt better when she rested or in the morning. She denied any trauma and said that they “just hurt all over” and could not indicate any point tenderness. She denied any joint stiffness, other joint pain, swelling, redness, rashes, or visual problems. She was obese and had not lost weight. She had gained ~20 pounds per report since her last visit to another physician 9 months previously. The past medical history was remarkable for being diagnosed 14 months ago with polycystic ovary syndrome (PCOS) after an evaluation for hirsutism and oligomenorrhea. The patient was supposed to be taking some medications, but she and her mother said that they really didn’t understand why she was taking the medicines so they just stopped a few months after starting them. They had moved and had not re-established care until presentation for the knee pain. The family history was positive for obesity, diabetes, and heart disease. The mother denied any gynecological problems in the family.

The pertinent physical exam showed an obese female who was slow to move around the room. Vital signs were pulse of 94, respiratory of 20, blood pressure of 136/72, weight of 197 lbs with a BMI of 32.1. Her skin examination showed significant acanthosis nigricans and comedomal acne. Her thyroid had no masses. Heart was regular rate and rhythm without murmur. Abdomen was obese with no hepatomegaly. Her joint examinations were normal without edema, erythema and general normal range of motion that was only limited by her weight. Her knees had no specific point tenderness, joint line tenderness and medial and cruciate ligaments were intact.

The diagnosis of deconditioning and joint pain secondary to weight gain was made. As the patient and family did not understand her underlying diagnosis of PCOS the patient was referred to a pediatric endocrinologist for patient education, evaluation and monitoring. The patient also had a well-child examination appointment made as it had been more than a year since her last one. She was also referred to a physical therapist to help with the joint pain and conditioning. The family also agreed to meet with the clinic social worker to help coordinate appointments, transportation, obtaining medical records and also helping the mother to establish medical care for herself and the other children in the family.

Discussion
Polycystic ovary syndrome (PCOS) affects 6-8% of reproductive-age women making it the most common endocrinopathy in this age group. There is no consensus on the specific diagnostic criteria for PCOS in adolescents as many of the characteristics overlap with normal adolescent physiology. However, patients should have evidence of hyperandrogenism, oligo- or amenorrhea, and potentially polycystic ovaries. PCOS has a genetic component although a specific gene has not been identified. Incidence of PCOS is 20-40% for a woman with a family history.

Hyperandrogenism
Androgen levels change during puberty therefore actual measurement and interpretation can make the diagnosis more difficult. Obesity increases androgens. Puberty is associated with a 25-50% decrease in insulin sensitivity. Therefore evidence of hyperandrogenism can be difficult to document.

Acne and hirsutism are common presentations. Hirsutism is the presence of terminal hairs in androgen dependent areas (i.e.male pattern) and is evidence of hyperandrogenism. Hypertrichosis is increase in vellus hair in non-male patterned areas such as forearms and lower legs and needs to be distinguished from hirsutism. Hypertrichosis is not evidence of hyperandrogenism. Patients may also have an increase in muscle mass or voice deepening.

Oligo- or amenorrhea
Anovulatory cycles are normal in pubertal girls so oligomenorrhea ( 2 years or have amenorrhea past the normal menarche should be considered for evaluation. This is especially true if hyperandrogen symptoms are present or if there is a family history of PCOS.

Polycystic ovaries
Multicystic ovaries are part of normal physiology for adolescent girls so diagnosis may overlap with adult criteria. Transvaginal ultrasound is a better imaging modality than transabdominal ultrasound for visualizing the ovaries. But many adolescents require transabdominal ultrasound because they are virginal or will not tolerate the procedure. Obesity also limits the adequacy of the transabdominal study.

The differential diagnosis of PCOS includes:

  • Congenital adrenal hyperplasia, late onset
  • Cushing syndrome
  • Hyperprolactinemia
  • Hypothyroidism
  • Pregnancy
  • Primary ovarian failure
  • Tumors – adrenal or ovary
  • Acromegaly

Treatment includes lifestyle modifications to improve obesity, insulin insensitivity and dyslipidemia. Oral contraceptives, usually combination medications, can improve menstrual irregularities, decrease androgens and improve hirsutism. Androgen receptor blockers such as spironolactone, also have similar effects. Insulin sensitizers such as metformin can improve insulin sensitization, menstrual irregularities and decrease androgens. Cosmetic methods of hair removal, and treatment of acne can also be helpful additional treatment for PCOS patients.


Learning Point

Potential health problems in PCOS include:

  • **Irregular menses
  • Infertility
  • Endometrial cancer
  • Obesity
  • Hyperlipidemia
  • Non-alcoholic fatty liver disease
  • Sleep apnea
  • **Acne
  • **Hirsutism
  • Insulin insensitivity, hyperglycemia
  • Type 2 diabetes
  • Acanthosis nigricans
  • Dyslipidemia
  • Hypertension

  • Emotional/psychiatric problems

** Common presentations of PCOS in adolescents

Questions for Further Discussion
1. What evaluation for PCOS should be considered?
2. What specialists help to manage PCOS?

Related Cases

    Symptom/Presentation: Pain

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Polycystic Ovary Syndrome and Knee Injuries and Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Irizarry KA, Brito V, Freemark M. Screening for metabolic and reproductive complications in obese children and adolescents. Pediatr Ann. 2014 Sep;43(9):e210-7.

Hecht Baldauff N, Arslanian S. Optimal management of polycystic ovary syndrome in adolescence. Arch Dis Child. 2015 Nov;100(11):1076-83.

Rosenfield RL. The Diagnosis of Polycystic Ovary Syndrome in Adolescents. Pediatrics. 2015 Dec;136(6):1154-65.

Morris S, Grover S, Sabin MA. What does a diagnostic label of ‘polycystic ovary syndrome’ really mean in adolescence? A review of current practice recommendations. Clin Obes. 2016 Feb;6(1):1-18.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital

LITFL Review 260

LITFL review

Welcome to the 260th LITFL Review! Your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the blogosphere’s best and brightest and deliver a bite-sized chunk of FOAM.

The Most Fair Dinkum Ripper Beauts of the Week

Nick CumminsA seriously good survival guide for central venous access devices from new DFTB author, Amanda Ullman. Includes tips to salvage almost any line. [JS]

The Best of #FOAMed Emergency Medicine

The Best of #FOAMcc Critical Care

  • There has been a surge of case-based Q&As related to ECMO activity on INTENSIVE in the past week: (1) Why is the bag turning red? discusses the identification and investigation of haemolysis in patients receiving ECMO support, (2) Cardiac arrest on VV ECMO is what it says on the tin, and (3)  Access insufficiency is just the beginning… shows, via a case of necrotizing pneumonia, that ECMO is not a universal panacea and lead to increasingly insoluble problems… Enjoy the #FOAMecmo! [CN]
  • Reuben Strayer shares his thoughts on the initial management of “Big Trauma” with a focus on avoiding the continued resuscitation in the trauma bay in lieu of rapidly getting the patient to CT or OR/IR. [AS]

The Best of #FOAMed Resuscitation

  • To cool or not to cool after ROSC? REBEL EM reviews the recent systematic review and meta-analysis in Resuscitation, pointing out some important issues with the contributory studies. [AS]

The Best of #FOAMtox Toxicology

The Best of #FOAMus Ultrasound

The Best of #FOAMped Paediatrics

  • A shining beacon for Paediatric EBM with a new journal study review feature: a welcome change filled with bubbles, glitter and probably bogies, fresh from the DFTB team. [CC]

The Best of #FOAMim Internal Medicine

The Best of #FOANed Nursing

The Best of Medical Education and Social Media

News from the Fast Lane

Reference Sources and Reading List

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Last update: Dec 5, 2016 @ 6:13 pm

The post LITFL Review 260 appeared first on LITFL: Life in the Fast Lane Medical Blog.

REMI 2186. Intensidad del tratamiento y final de la vida en el paciente anciano con traumatismo craneoencefálico grave

ARTÍCULO ORIGINAL: Intensity of treatment, end-of-life care, and mortality for older patients with severe traumatic brain injury. Lilley EJ, Williams KJ, Schneider EB, Hammouda K, Salim A, Haider AH, Cooper Z. J Trauma Acute Care Surg. 2016 Jun;80(6):998-1004. doi: 10.1097/TA.0000000000001028. [Resumen] [Artículos relacionados]
  
INTRODUCCIÓN: El traumatismo craneoencefálico (TCE) grave en la población geriátrica tiene respecto a la población joven mayor morbimortalidad, peor resultado funcional y alta probabilidad de institucionalización. La participación de la familia es muy importante para planificar el plan terapéutico y de cuidados cuando se decide la limitación de tratamientos agresivos. La Eastern Association for the Surgery of Trauma (EAST) posee recomendaciones para el manejo de pacientes geriátricos con TCE grave [1]; sin embargo, no define adecuadamente los términos utilizados para la toma de decisiones.
   
RESUMEN: Estudio retrospectivo de 4 años de los pacientes con edad ≥ 65 años y TCE grave. Analizan entre otras variables: mecanismo de producción, gravedad, días de estancia hospitalaria, decisiones al final de la vida, comorbilidades, puntuación en la escala de Glasgow para el coma (GCS) a las 72 horas y estado funcional y mortalidad al año. Los pacientes fueron clasificados en: “muerte precoz” si ocurrió antes de las 72 horas, “no respondedores y “respondedores” según el estado funcional neurológico tras el tratamiento. Aunque las guías EAST no definen dicho estado funcional, otros estudios lo definen como persistencia del estado comatoso con GCS < 8 a las 72 horas y pobre pronóstico. Hubo un total de 90 pacientes, siendo las caídas la causa más frecuente de producción del traumatismo (83%), el 32% fueron muertes precoces, 32% “no respondedores” y 34% “respondedores”. Del total de pacientes “no respondedores”, 17 fallecieron en el hospital: 65% atribuido a la lesión cerebral, insuficiencia respiratoria 24%, parada cardiaca 6% y disfunción multiorgánica (DMO) 6%. Dos pacientes del grupo “respondedores” murieron en el hospital por insuficiencia respiratoria y DMO. Al alta, un equipo multidisciplinar evaluó el estado funcional y objetivó dependencia para una o más actividades de la vida diaria (AVD) en el 100% del total de pacientes y en el 80% de los “respondedores”. No hubo ningún paciente independiente para AVD. No hubo diferencias significativas de mortalidad al año en ambos grupos de pacientes. 
  
COMENTARIO: El estudio muestra que los pacientes geriátricos con TCE grave pueden ser clasificados en “respondedores” o no “respondedores” al tratamiento, siendo en éste último grupo de pacientes los que continúan en coma con GCS < 8 puntos después de 72 horas de tratamiento y en los que el médico debería valorar la limitación de tratamientos médicos agresivos y el final de la vida, debido a la alta mortalidad y al pobre estado funcional postraumatismo. El EAST es cauto al hacer referencias a estas decisiones, ya que existe un periodo incierto en la evolución de los pacientes, de forma que es importante el debate interdisciplinar con familiares y medicina paliativa. Los tratamientos agresivos de los pacientes al final de la vida se asocian a peor calidad de asistencia y mayor coste, de ahí que se estén elaborando documentos de consenso entre familiares, médicos y paliativos para mejorar la comunicación entre los implicados en la atención del paciente. Se precisa mejor definición de “pobre pronóstico” e identificar claramente  los indicadores clínicos que ayuden a la toma de estas decisiones, así como realizar estudios en subgrupos de edad a partir de los 65 años. 
   
Encarnación Molina Domínguez
Hospital General de Ciudad Real.
© REMI, http://medicina-intensiva.com. Diciembre 2016.
      
ENLACES:
  1. EAST Practice Management Guidelines. Triage of Geriatric Trauma (2001). [HTML] [PDF]
  2. Patients with severe traumatic brain injury transferred to a Level I or II trauma center: United States, 2007 to 2009. Sugerman DE, Xu L, Pearson WS, Faul M. J Trauma Acute Care Surg. 2012 Dec;73(6):1491-9. [PubMed]
  3. Death after discharge: predictors of mortality in older brain-injured patients. Peck KA, Calvo RY, Sise CB, Johnson J, Yen JW, Sise MJ, Dunne CE, Badiee J, Shackford SR, Lobatz MA.J Trauma Acute Care Surg. 2014 Dec;77(6):978-83. [PubMed]
  4. Traumatic Brain Injury in the Elderly: Is it as Bad as we Think? Mak CH, Wong SK, Wong GK, Ng S, Wang KK, Lam PK, Poon WS. Curr Transl Geriatr Exp Gerontol Rep. 2012 Jul 6;1:171-178. [PubMed] [Texto completo]
BÚSQUEDA EN PUBMED:
  • Enunciado: Pronóstico del traumatismo craneoencefálico grave en ancianos
  • Sintaxis: severe head trauma older adults prognosis
  • [Resultados]